To our knowledge, this study is the first to quantitatively examine the lifestyle and health risk behaviors of physicians, nurses, and community health workers (CHWs) in Brazil. It provides data to measure progress in nationwide initiatives. For example, the Brazilian government embarked on a strategic plan 2011–2022 to address the increasing rates of NCDs. According to the Ministry of Health (2011), the plan’s goal is to decrease the premature mortality rates of NCDs for those under the age of 70 by 2 % per year, to decrease obesity prevalence among children and adolescents, and reduce exposure to risk factors such as smoking, alcohol consumption, lack of physical activity, and salt consumption [26]. “During the development of this national plan, the Brazilian Government took account of the results of evaluation studies of community interventions to promote physical activity, particularly physical activity classes in community settings through programs such as the Academia da Cidade in Recife, Aracaju, and Belo Horizonte” [26] (page 7). In this sense, information from this nationwide survey among health care professionals of Brazil can help to establish a baseline before specific actions and policies are implemented and encouraged by the government. Yet, the descriptive nature of the analysis in this paper, rather than multivariate correlation analyses, which would have allowed the authors to adjust for socio-demographic variables, limits the reach of the conclusions. For instance, it is difficult to discern if many of the differences between nurses, CHWs, and physicians are due to differences in age and gender versus professional backgrounds.
The results from this study will be used as a baseline to understand health behaviors and counseling among primary health care professionals in Brazil and assess the ambitious national plan for reducing population rates of NCDs. A reasonably high percentage of physicians, nurses, and CHWs do not engage in healthy lifestyle behaviors that impact chronic diseases. Based on current evidence, this suggests that they are less likely to encourage these healthy behaviors in their patients [2, 5].
Large differences were found between sleep hours reported by the three groups of professionals. More CHWs got 9(+) hours of sleep (close to 10 %) compared to nurses and physicians (about 5 % and 3 %, respectively); this may be due to a higher prevalence of longer shifts among nurses and doctors. In the United States, sleep deprivation, substance abuse, anxiety, and depression are factors contributing to medical error, as well as to higher rates of work-related injuries for medical residents in training [7, 27]. Thus, it is important to pay attention to the workload and reduced quality and amount of sleep among medical professionals due to the potential harmful impact this can have on the patients. A main finding from this study was that CHWs had the highest prevalence of currently smoking (7.4 %). This may be due to the fact that CHWs do not necessarily have to work at health care institutions in which there are often bans on smoking within or near the facility.
A specific strength of this study is that it reflects the distribution of CHWs in Brazil in relation to age and gender, decreasing the likelihood of selection bias [28, 34]. A CHW can be defined as “any health worker carrying out functions related to health care delivery, trained in some way, in the context of the intervention; and having no formal professional or paraprofessional certificated or degreed tertiary education” [29] (page 3). Because CHWs have less degreed tertiary education compared to nurses and physicians, it is understandable that they may feel unprepared to talk to their patients about how to maintain healthy lifestyles, including nutrition, physical activity, weight control, and counseling on breast and cervical cancers. Breast and cervical cancer are the two most frequent cancer types among women in Brazil [30, 31], which justifies their inclusion in this study. A recent paper on cervical cancer prevention published with data from this survey found that although most primary health care units conducted screening, they also used home visits to conduct recruitment and outreach and provided follow-up. More training and information on effective prevention and screening strategies is needed, particularly for CHWs who offer more direct contact with women at the community level [31].
Certification and training programs for CHW in Brazil that focus on nutrition and physical activity could be implemented to take full advantage of the universal nature of the health care system and their engagement with community members. Moreover, physicians, nurses, and CHWs would greatly benefit from an exchange of information and knowledge regarding real needs and health concerns of the community. However, a review of 109 articles shows that CHWs and medical providers are rarely trained together, limiting opportunities for exchange of knowledge and skills from diverse sources and perspectives [32]. In the United States, continuing education workshops help keep health professionals updated on new public health research and ways to better serve patients and increasingly inter-professional learning (IPL) programs are being encouraged at the institutional and academic level so that healthcare students are better prepared to become cross disciplinary professionals [33]. The results of this study suggest that continuing education workshops and IPL may help increase the percentage of physicians, nurses, and CHWs in Brazil who feel prepared to counsel their patients [34]. Furthermore, another published article that was completed using the data collected from this same study’s questionnaire, found that nearly 40 % of the health professionals in Brazil incorrectly believed ninety minutes of moderate-intensity physical activity per week is the recommended amount for health benefits, when the actual recommended amount by WHO is accumulating 150 min per week of moderate to vigorous-intensity physical activity [35]. This could be part of the government strategy to reduce the incidence of NCD at the national level.
Although cancer was not the main focus of this paper, physicians in this study may not be advising their advanced stage cancer patients to practice physical activity due to a perception that these patients may not have the strength to practice physical activity. Yet, depending on the type of cancer and the stage, physical activity can help a cancer patient. According to the American Cancer Society, research has shown that exercise is not only safe and possible during cancer treatment, but it can improve physical function and quality of life [36–38]. The only time cancer patients should not practice physical activity is when it causes pain, rapid heart rate, or shortness of breath [39].
This study was based on self-report and self-perception data, thus information about socially undesirable behaviors such as smoking and alcohol use may be underreported, limiting the results from this study. The field interviewers interviewed 1,200 respondents, but 400 participants did not respond to all of the questions. A non-monetary reward, such as a fruit basket, for the participants should have been provided for taking the time to answer all the questions, since it could have helped increase the response rate. The distribution of the response rate is not the same within the three health professional groups, which could have also led to response bias, when analyzing the sample in its entirety. The low response rate in this study can be explained by the refusal of health care workers to take time away from their responsibilities and also to answer personal questions about their own lifestyles. Additionally, the survey took approximately 45 min to answer, which is a considerable amount of time for a health practitioner. It is common to have low response rates among health professionals, especially physicians.
It is difficult to determine to what extent health professionals would be willing to admit they are not prepared to counsel their patients on certain topics since most health professionals have an ethical responsibility to stay up-to-date and knowledgeable about best evidence-based practices that can assist their patients. Yet, people are more likely to be honest and open to disclosure when there is greater “social distance,” specifically between respondents and their interviewers [40]. A more distant telephone interviewer will have less of a social influence and will less likely elicit either favorable or unfavorable reactions from the respondent. Thus, one advantage of this study is the use of the telephone based survey since more social desirability bias may occur in face-to-face interviews than over the telephone [40].
In addition, alcohol consumption questions were not specific in the survey, for example, there was no operationalized definition of binge drinking (frequency for which an individual consumes more than three alcoholic beverages in a 4-h period during an average week and dosage effects) [1, 41, 42]. This could have limited our ability to interpret and report the results.
One of the major contributions from this study is that our findings are new and provide current and unique information about health professionals’ behaviors in Brazil. There are many studies about medical and nurse student behaviors, but there are few on practicing physicians, nurses, or CHWs. This study also brings to light base line information in regard to health professionals’ need to improve their lifestyle behaviors so that they can potentially feel more prepared and equipped to counsel their patients. Additionally, our study’s findings can encourage more partnerships and advocacy for changes or improvements in the existing national health policies in Brazil. Other strengths of this study include the selection of a representative group of health care professionals from all 5 regions of Brazil (North, South, North East, South East, and Central West) and a high response rate (more than 50 %) for nurse and CHW participants.